Developing a deep learning model for sleep stage prediction in obstructive sleep apnea cohort using 60 GHz frequency-modulated continuous-wave radar.

Given the significant impact of sleep on overall health, radar technology offers a promising, non-invasive, and cost-effective avenue for the early detection of sleep disorders, even prior to relying on polysomnography (PSG)-based classification. In this study, we employed an attention-based bidirectional long short-term memory (Attention Bi-LSTM) model to accurately predict sleep stages using 60 GHz frequency-modulated continuous-wave (FMCW) radar. Our dataset comprised 78 participants from an ongoing obstructive sleep apnea (OSA) cohort, recruited between July 2021 and November 2022, who underwent overnight polysomnography alongside radar sensor monitoring. The dataset encompasses comprehensive polysomnography recordings, spanning both sleep and wakefulness states. The predictions achieved a Cohen's kappa coefficient of 0.746 and an overall accuracy of 85.2% in classifying wakefulness, rapid-eye-movement (REM) sleep, and non-REM (NREM) sleep (N1 + N2 + N3). The results demonstrated that the models incorporating both Radar 1 and Radar 2 data consistently outperformed those using only Radar 1 data, indicating the potential benefits of utilising multiple radars for sleep stage classification. Although the performance of the models tended to decline with increasing OSA severity, the addition of Radar 2 data notably improved the classification accuracy. These findings demonstrate the potential of radar technology as a valuable screening tool for sleep stage classification.

B-Cell Lymphoma Arising From a Nasal Implant: A Brief Clinical Study.

Continuous exposure to foreign substances initiates a sustained inflammatory reaction in the body, and subsequent chronic inflammation is recognized as one of the causes of lymphoma. Most lymphomas caused by foreign bodies are composed of 2 major phenotypes. Diffuse large B-cell lymphoma arising from metallic prosthesis, also called metallic implant-associated lymphoma and T-cell phenotype anaplastic large cell lymphoma, commonly associated with breast implants. Augmentation rhinoplasty is often performed to improve the esthetics of the nasal dorsum and various synthetic materials have been used as implants. The occurrence of lymphoma originating from a nasal implant is scarcely documented, and even more uncommon is its manifestation as epstein-barr virus (EBV)-negative extranodal marginal zone lymphoma. Here, the authors describe a rare case of B-cell lymphoma of the nose and nasolacrimal duct in a 49-year-old woman who underwent rhinoplasty with a silicone implant 20 years ago.

Gray matter volume reduction in the emotional brain networks in adults with anosmia.

Loss of olfaction, or anosmia, frequently accompanies emotional dysfunctions, partly due to the overlapping brain regions between the olfactory and emotional processing centers. Here, we investigated whether anosmia was associated with gray matter volume alterations at a network level, and whether these alterations were related to the olfactory-specific quality of life (QOL) and depressive symptoms. Structural brain magnetic resonance imaging was acquired in 22 individuals with postinfectious or idiopathic anosmia (the anosmia group) and 30 age- and sex-matched controls (the control group). Using independent component analysis on the gray matter volumes, we identified 10 morphometric networks. The gray matter volumes of these networks were compared between the two groups. Olfactory-specific QOL and depressive symptoms were assessed by self-report questionnaires and clinician-administered interviews, respectively. The anosmia group showed lower gray matter volumes in the hippocampus-amygdala and the precuneus networks, relative to the control group. Lower gray matter volumes in the hippocampus-amygdala network were also linearly associated with lower olfactory-specific QOL and higher depressive symptom scores. These findings suggest a close relationship between anosmia and gray matter volume alterations in the emotional brain networks, albeit without determined causal relations.

Effect of sinus opacification on the severity of obstructive sleep apnea.

PURPOSE: The association between rhinosinusitis and obstructive sleep apnea (OSA) remains unclear. Here, we aimed to elucidate the association between sinus opacification and OSA severity. METHODS: Patients with snoring problems who visited our clinic from April 2018 to December 2020 were retrospectively enrolled. Among these patients, we included those who underwent a physical examination, overnight polysomnography, and osteomeatal-unit computed tomography. We evaluated the association between apnea-hypopnea index (AHI) and Lund-Mackay score (LMS). LMS ≥ 5 was considered indicative of sinus opacification. RESULTS: Among the 122 patients included in the study, LMS exhibited an increasing trend based on OSA severity. The LMS in the moderate OSA group was significantly higher than that in the no OSA group (P = 0.002), and the LMS in the severe OSA group was significantly higher than that in the no OSA (P < 0.001) and mild OSA (P = 0.006) groups. A correlation analysis revealed that AHI was significantly associated with body mass index (BMI) (r = 0.367, P < 0.001) and LMS (r = 0.255, P = 0.005). A multivariate analysis revealed that sinus opacification was associated with moderate and severe OSA [Adjusted odds ratio = 11.986 (P = 0.005) and 3.756 (P = 0.044), respectively] after adjusting for age, sex, BMI, smoking, hypertension, atopy, tonsil size, and palatal position. The effect of sinus opacification on OSA severity was comparable to that of overweight. CONCLUSION: Sinus opacification may increase OSA severity since moderate and severe OSA is independently associated with it.

Automated Detection of Sleep Apnea-Hypopnea Events Based on 60 GHz Frequency-Modulated Continuous-Wave Radar Using Convolutional Recurrent Neural Networks: A Preliminary Report of a Prospective Cohort Study.

Radar is a promising non-contact sensor for overnight polysomnography (PSG), the gold standard for diagnosing obstructive sleep apnea (OSA). This preliminary study aimed to demonstrate the feasibility of the automated detection of apnea-hypopnea events for OSA diagnosis based on 60 GHz frequency-modulated continuous-wave radar using convolutional recurrent neural networks. The dataset comprised 44 participants from an ongoing OSA cohort, recruited from July 2021 to April 2022, who underwent overnight PSG with a radar sensor. All PSG recordings, including sleep and wakefulness, were included in the dataset. Model development and evaluation were based on a five-fold cross-validation. The area under the receiver operating characteristic curve for the classification of 1-min segments ranged from 0.796 to 0.859. Depending on OSA severity, the sensitivities for apnea-hypopnea events were 49.0-67.6%, and the number of false-positive detections per participant was 23.4-52.8. The estimated apnea-hypopnea index showed strong correlations (Pearson correlation coefficient = 0.805-0.949) and good to excellent agreement (intraclass correlation coefficient = 0.776-0.929) with the ground truth. There was substantial agreement between the estimated and ground truth OSA severity (kappa statistics = 0.648-0.736). The results demonstrate the potential of radar as a standalone screening tool for OSA.

Bone morphogenetic protein-2 as a novel biomarker for refractory chronic rhinosinusitis with nasal polyps.

BACKGROUND: Bone morphogenetic proteins (BMPs), which are members of the TGF-ß superfamily, regulate bone remodeling by stimulating osteoblasts and osteoclasts. Although the association between osteitis and poor surgical outcomes is well known in patients with chronic rhinosinusitis (CRS), BMPs have not been fully investigated as potential biomarkers for the prognosis of CRS. OBJECTIVE: Our aim was to investigate the role of BMPs in osteitis in patients with CRS with nasal polyps (NPs) (CRSwNPs), as well as associations between BMPs and inflammatory markers in sinonasal tissues from patients with CRSwNP. METHODS: We investigated the expression of 6 BMPs (BMP-2, BMP-4, BMP-6, BMP-7, BMP-9, and BMP-10) and their cellular origins in NPs of human subjects by using immunohistochemistry and ELISA of NP tissues. Exploratory factor analysis was performed to identify associations between BMPs and inflammatory markers. Air-liquid interface cell culture of human nasal epithelial cells was performed to evaluate the induction of the epithelial-mesenchymal transition by BMPs. RESULTS: Of the 6 BMPs studied, BMP-2 and BMP-7 were associated with refractoriness. Only BMP-2 concentrations were higher in patients with severe osteitis and advanced disease extent according to the computed tomography findings. Eosinophils and some macrophages were identified as cellular sources of BMP-2 in immunofluorescence analysis. An in vitro experiment revealed that BMP-2 induced epithelial-mesenchymal transition in air-liquid interface-cultured human nasal epithelial cells, particularly in a TH2 milieu. CONCLUSION: BMP-2 could reflect the pathophysiology of mucosa and bone remodeling and may be a novel biomarker for refractory CRSwNP.

Clinical characteristics of asymptomatic allergen sensitization with nasal septal deviation, often misdiagnosed as allergic rhinitis.

PURPOSE: Allergic rhinitis (AR) is often defined based on symptoms accompanied by a positive allergen sensitivity test result. However, a positive skin prick test (SPT) does not always imply the occurrence of clinical symptoms. If an asymptomatic allergen-sensitized patient has nasal septal deviation (DSN) that could cause nasal obstruction, the condition could easily be confused with typical symptomatic AR. This study investigated the clinical and laboratory characteristics of asymptomatic allergen-sensitization with septal deviation (ASSD). METHODS: Patients from a nationwide AR cohort study, conducted in 8 university hospitals, were investigated. AR was diagnosed when there were at least 1 rhinitis symptom with a positive SPT result. The ASSD group included patients who had severe nasal obstruction with few other symptoms and a positive SPT, along with septal deviation. Clinical and laboratory characteristics were compared between the ASSD group and the true AR group. RESULTS: In total, 728 patients were included. The average age was 32.2 ± 12.7 and 66% of the patients had DSN. SPT indicated that ASSD patients were less sensitized to house dust mite (p = 0.019 for Dp and p = 0.021 for Df). There was a significant sex difference: the male-to-female ratio was higher in the ASSD than in the AR group (3.59 vs. 1.77, p = 0.012). However, no statistically significant differences in age, family history, and body mass index were found. CONCLUSION: ASSD can mimic AR. When dealing with allergen-sensitized patients with a predominant symptom of nasal obstruction, DSN might also be considered before confirming a diagnosis of AR.

A Patient Presentation of Large Septal Perforation Repair Using Inferior Based Contra-Lateral Nasal Floor Flap, a New Surgical Technique for Large Septal Perforation.

ABSTRACT: A nasal septal perforation is a defect of cartilage, bone, or mucosa of nasal septum, which is caused by previous septal surgery, trauma, chemicals, inflammatory disease, or drugs. If conservative managements, such as nasal saline irrigation or ointments, are not effective, surgical treatment can be considered. Various methods for the reconstruction of nasal septal perforation were reported, such as local flaps, free flaps, autografts, allografts, or xenografts. However, there is no standardized method due to low success rate and high recurrence rate, especially in large perforations. The authors report a successful repair case of large anteroinferior nasal septal perforation, using inferior based contralateral nasal floor flap. The authors believe that our method is an effective way to repair large nasal septal perforation and to minimalize donor site morbidity, without using other allografts.

Superantigen-related TH2 CD4+ T cells in nonasthmatic chronic rhinosinusitis with nasal polyps.

BACKGROUND: Staphylococcus aureus enterotoxin (SAE) superantigens are detected in nasal polyps (NPs), and SAE-specific IgE predicts asthma comorbidity in patients with NPs. However, roles of SAE superantigens and superantigen-related T-cell responses remain to be elucidated in nonasthmatic patients. OBJECTIVE: We investigated the presence of SAEs and SAE-related T-cell receptor (TCR) Vß (TCRVß) in nonasthmatic NPs, the phenotypes and functions of SAE-related T cells, and the clinical implication of SAE-related T-cell expansion. METHODS: Sinonasal tissue samples were obtained from patients with nonasthmatic chronic rhinosinusitis (CRS) with NPs (CRSwNP), patients with CRS without NPs (CRSsNP), and control subjects. SAE genes were detected by PCR, and the TCRVß distribution and T-cell phenotypes were examined by flow cytometry. RESULTS: Various SAE genes were detected not only in NPs but also in sinonasal mucosa from patients with CRSsNP and from controls. The S aureus enterotoxin I (SEI) gene was detected in all NPs. The fraction of SEI-responsive TCRVß+ (TCRVß1+ and Vß5.1+) CD4+ T cells was significantly increased only in NPs and the ethmoidal mucosa of patients with CRSwNP, indicating superantigen-induced expansion. The expanded TCRVß5.1+ CD4+ T cells expressed proliferation marker Ki-67 and the TH2 transcription factor GATA3. Furthermore, TCRVß5.1+ CD4+ T cells in NPs highly expressed TH2 markers, including IL-17RB, thymic stromal lymphoprotein receptor, and chemoattractant receptor-homologous molecule expressed on TH2 cells, with a potent TH2 cytokine-producing ability. Moreover, the expansion of TCRVß1+ or Vß5.1+ CD4+ T cells was associated with the Lund-Mackay computed tomography score, indicating disease extent. CONCLUSION: In nonasthmatic patients with CRSwNP, superantigen-related expansion of CD4+ T cells with TH2 differentiation was associated with the disease extent.

Necrotizing sialometaplasia: a malignant masquerade but questionable precancerous lesion, report of four cases.

BACKGROUND: Necrotizing sialometaplasia (NSM) is an extremely rare benign lesion with an uncertain pathogenesis. The differential diagnosis of this lesion is challenging due to little familiarity with this entity and histologic similarity with carcinomas, especially mucoepidermoid carcinoma (MEC). The purpose of this study is to raise awareness about NSM, which is often overlooked or misdiagnosed as malignancy in a small biopsy. METHODS: We reviewed all biopsy materials taken from the oral cavity in a single institution in Korea from 2012 to 2018 and found 4 cases of NSM out of 726. Clinicopathologic characteristics and comparison with other lesions were discussed. RESULTS: Unlike previous reports, patients in our series were relatively young, and NSM was not related to smoking and not associated with malignancies, although one patient was misdiagnosed with MEC on the basis of the initial biopsy. High-grade squamous dysplasia was observed in one patient; however, all four patients showed excellent prognoses without further management. CONCLUSIONS: A conservative approach is recommendable for necrotizing lesions of the palate in young adults to avoid unnecessary treatment. However, careful monitoring is also required due to uncertainty of premalignant potential.

The effect of body position on airway patency in obstructive sleep apnea: CT imaging analysis.

PURPOSE: Positional change during sleep influences upper airway patency. However, few studies have used imaging techniques to demonstrate the change. This study aims to determine the effect of positional change on the upper airway space. METHODS: A total of 118 subjects with sleep breathing disorders were analyzed. Participants underwent upper airway CT scans in the supine and lateral decubitus positions (right and left). They were divided into non-obstructive sleep apnea (n = 28) and obstructive sleep apnea (n = 90) groups. We measured the minimal cross-sectional area of the retropalatal/retroglossal spaces and compared the differences of those two spaces in the supine and lateral positions. CT was performed while patients were awake. RESULTS: The minimal cross-sectional area in the OSA group was significantly smaller than non-OSA group in both supine (median[interquartile range], 8.3[0.0-25.1] vs 22.2[1.0-39.6]; P = 0.018) and lateral decubitus positions (5.2[0.0-16.9] vs 21.3[6.1-38.4]; P = 0.002). As the body position of OSA patients shifted from supine to lateral, the retroglossal space increased significantly (67.3[25.1-116.3] vs 93.3[43.4-160.1]; P < 0.001). However, there was no significant difference in the retropalatal space between the supine and lateral decubitus positions. CONCLUSIONS: Positional change from the supine to lateral decubitus position expands the upper airway lumen, especially the retroglossal space. Positional OSA may be related to anatomical change of the upper airway lumen based on body position.

Soft palate cephalometric changes with a mandibular advancement device may be associated with polysomnographic improvement in obstructive sleep apnea.

PURPOSE: It is unclear whether soft palate-associated changes in cephalometry associated with a mandibular advancement device (MAD) are independently associated with improvements in polysomnography (PSG) respiratory parameters in obstructive sleep apnea (OSA). METHODS: This retrospective review aimed to identify the association between soft palate-associated changes in cephalometry and PSG changes after application of an MAD. Korean patients diagnosed with OSA who underwent cephalometry with or without an MAD were enrolled. All the patients were evaluated after undergoing full-night PSG twice: once with an MAD and once without. Cephalometric findings were measured using an image analyzer. RESULTS: Mean apnea-hypopnea index significantly decreased with an MAD from 36.4/h to 14.7/h (p < 0.001). Retropalatal airway space significantly increased with an MAD from 6.6 to 7.3 mm (p = 0.013). Soft palate length also significantly decreased with an MAD from 43.6 to 42.3 mm (p = 0.02). Although these findings were shown by responders (patients with a reduction of apnea-hypopnea index by more than 50%), there were no significant changes in non-responders. However, retroglossal airway space did not significantly increase with an MAD even in responders. CONCLUSIONS: Improvement of OSA with an MAD can be predicted with soft palate-associated upper airway changes shown in cephalometry.

Chronic rhinosinusitis with nasal polyps is associated with chronic otitis media in the elderly.

Chronic rhinosinusitis (CRS) and chronic otitis media (COM) are common diseases in the otorhinolaryngology field. Although clinicians frequently encounter patients presenting both diseases simultaneously, a few studies have shown relationships between them. We examined whether CRS was associated with COM in adults who participated in the Korea National Health and Nutrition Examination Survey from 2009 to 2012. A total of 27,492 participants were examined in this cross-sectional epidemiological study. Regression analyses was performed and adjusted for socio-demographics, general health behavior, and other comorbidities. All analyses used complex sampling designs; subgroup analyses were performed according to age, hearing loss, and the presence of cholesteatoma or nasal polyps. The weighted prevalence of COM and CRS was 3.6 ± 0.2 and 6.0 ± 0.2%, respectively. COM prevalence was significantly higher in subjects with CRS (5.1%) than in those without (3.5%). In the multivariate analysis, COM was more prevalent in subjects with CRS (adjusted odds ratio = 1.738; P = 0.038) after adjusting for other factors. The subgroup analysis showed that this association was significant only in older subjects (≥50 years) with nasal polyps. Non-serviceable hearing and cholesteatoma were not significantly associated with CRS. Our findings demonstrated that CRS with nasal polyps might be associated with COM in older patients.

Changes in Structural Covariance among Olfactory-related Brain Regions in Anosmia Patients.

Anosmia, characterized by the loss of smell, is associated not only with dysfunction in the peripheral olfactory system but also with changes in several brain regions involved in olfactory processing. Specifically, the orbitofrontal cortex is recognized for its pivotal role in integrating olfactory information, engaging in bidirectional communication with the primary olfactory regions, including the olfactory cortex, amygdala, and entorhinal cortex. However, little is known about alterations in structural connections among these brain regions in patients with anosmia. In this study, high-resolution T1-weighted images were obtained from participants. Utilizing the volumes of key brain regions implicated in olfactory function, we employed a structural covariance approach to investigate brain reorganization patterns in patients with anosmia (n=22) compared to healthy individuals (n=30). Our structural covariance analysis demonstrated diminished connectivity between the amygdala and entorhinal cortex, components of the primary olfactory network, in patients with anosmia compared to healthy individuals (z=-2.22, FDR-corrected p=0.039). Conversely, connectivity between the orbitofrontal cortex-a major region in the extended olfactory network-and amygdala was found to be enhanced in the anosmia group compared to healthy individuals (z=2.32, FDR-corrected p=0.039). However, the structural connections between the orbitofrontal cortex and entorhinal cortex did not differ significantly between the groups (z=0.04, FDR-corrected p=0.968). These findings suggest a potential structural reorganization, particularly of higher-order cortical regions, possibly as a compensatory effort to interpret the limited olfactory information available in individuals with olfactory loss.

Endotype and Phenotype Related Postoperative Effects of Bacterial Lysate in Chronic Rhinosinusitis.

OBJECTIVES: Chronic rhinosinusitis (CRS) endotypes have demonstrated clinical value in guiding treatment decisions. Bacterial lysates are immunomodulators that have shown beneficial effects in various respiratory inflammatory diseases. This study aimed to evaluate the effect of postoperative bacterial lysate therapy on different CRS endotypes. METHODS: Patients diagnosed with CRS who underwent endoscopic sinus surgery were recruited. Bacterial lysates were administered postoperatively for 10 days per month for 3 months to the experimental group comprising patients with a history of frequent upper respiratory infections without adverse reactions. The remaining participants were allocated to the control group. The results of the postoperative 3-, 6-, and 12-month assessments, including the modified Lund-Kennedy (mLK) endoscopic and Sinonasal Outcome Test (SNOT) 22 scores, for the groups were compared. The tissue samples obtained from the participants were evaluated to detect the presence of relevant inflammatory mediators. RESULTS: Among the 92 participants, 47 started bacterial lysate therapy 2 weeks after the surgery. The tissue cytokine profiles and clinical parameters, such as the disease severity and blood eosinophil percentage, of the bacterial lysate and control groups were comparable before treatment. The mLK endoscopic and SNOT-22 scores did not differ after 3, 6, and 12 months of follow-up. The subgroup analysis revealed that the bacterial lysate group had significantly lower mLK endoscopic scores than the control group for CRS without nasal polyps, while there was a tendency toward significance for the interleukin (IL)-5 negative group after 6 months. CONCLUSION: Postoperative bacterial lysate therapy has some beneficial effects on the endoscopic findings of patients with CRS without nasal polyps or those who are negative for IL-5.

Clinical and immunologic implication of neo-osteogenesis in chronic rhinosinusitis.

INTRODUCTION: Chronic rhinosinusitis (CRS) is a multifactorial disease characterized by long-term inflammation of the nasal and sinus passages. Neo-osteogenesis which is a major finding of recalcitrant CRS is clinically related to the disease severity and surgical outcomes of CRS. AREAS COVERED: The immunological and molecular mechanisms underlying neo-osteogenesis of CRS remain unclear, and many recent studies have suggested the importance of inflammatory mediators secreted by immune cells. This paper provides a broader understanding of neo-osteogenesis in CRS by reviewing recent updates and evidence of the association between CRS pathophysiology and neo-osteogenesis. EXPERT OPINION: Crosstalk between the bone and mucosa eventually results in refractory CRS. In addition, both eosinophilic and non-eosinophilic CRS cytokines can play a role in neo-osteogenesis and trigger an enhanced CRS-associated immune response. The significance of predicting neo-osteogenesis in advance or during postoperative care could be essential for effectively managing refractory CRS and enhancing the prognosis of CRS patients.

The Role of Fractional Exhaled Nitric Oxide in Diagnosing Asthmatic Type 2 Chronic Rhinosinusitis With Nasal Polyps.

BACKGROUND: Fractional exhaled nitric oxide (FeNO) is useful in the management of asthma and predicting the efficacy of standard corticosteroids and biologics. However, the diagnostic value of FeNO in asthmatic chronic rhinosinusitis with nasal polyps (CRSwNP) remains unclear. OBJECTIVE: We assessed FeNO levels in patients with CRSwNP and evaluated the diagnostic value of FeNO for screening type 2 CRSwNP (T2-CRSwNP) with asthma. METHODS: We enrolled 94 patients who were diagnosed with CRSwNP and underwent functional endoscopic sinus surgery. FeNO levels, the blood eosinophil percentage, total IgE, spirometry tests (FEV1/FVC), Lund-Mackay CT score, and percentage of patients with comorbid asthma were compared among CRSwNP subgroups. Spearman rank correlation test was used to assess the degree of association between variables. ROC curve analysis was conducted to evaluate the diagnostic capability to differentiate T2-CRSwNP based on clinical and histological classifications. RESULTS: FeNO levels and the blood eosinophil percentage were significantly higher in patients with T2-CRSwNP(h) based on histological data (P < .05). FeNO was correlated with the blood eosinophil percentage (r = 0.420, P < .001) and FEV1/FVC (r = -0.324, P = .001). A FeNO level of 27 ppb had a good ability to discriminate patients with asthmatic T2-CRSwNP(h) (AUC = 0.848; 95% CI = 0.7602-0.9361; sensitivity = 90.9%; specificity = 63.9%). The optimal cutoff values for FeNO and the blood eosinophil percentage for diagnosing asthmatic T2-CRSwNP(h) were 68 ppb and 5.6% (sensitivity = 95.5%; specificity = 86.1%; AUC = 0.931; 95% CI = 0.8832-0.9791). In the diagnosis of severe T2-CRSwNP(c) based on clinical data, a FeNO level of 36 ppb showed the highest AUC (0.816; 95% CI = 0.7173-0.914; sensitivity = 72.7%; specificity = 79.2%). CONCLUSION: FeNO is a useful marker for screening asthmatic T2-CRSwNP even prior to biopsy or asthma evaluation and may assist in selecting a proper treatment.

Effects of Neutrophil and Eosinophil Extracellular Trap Formation on Refractoriness in Chronic Rhinosinusitis With Nasal Polyps.

PURPOSE: This study investigated the clinical implications of neutrophil extracellular trap (NET) formation (NETosis) and eosinophil extracellular trap (EET) formation (EETosis) regarding refractoriness in chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP). METHODS: Nasal polyp specimens were obtained from 117 patients with CRSwNP who received endoscopic sinus surgery. Disease control status at postoperative 1 year was assessed. Refractory cases were defined as partly controlled or uncontrolled cases according to the EPOS 2020 guidelines. NETosis and EETosis were evaluated through immunofluorescence staining (citrullinated histone H3-human neutrophil elastase and citrullinated histone-galectin-10, respectively) followed by manual counting. The z-score of NET and EET counts was used to define the following four groups: low extracellular trap formation (ETosis), NETosis-predominant, EETosis-predominant, and high-ETosis. RESULTS: The refractory and non-refractory groups showed significant differences in the tissue eosinophil count (P = 0.005) and EET count (P = 0.029). The tissue neutrophil count and the NET/neutrophil ratio were significantly different between the refractory and non-refractory groups of patients with neutrophilic CRS (P = 0.045, 0.031, respectively). Refractoriness significantly differed among the low-ETosis (30.77%), NETosis-predominant (47.83%), EETosis-predominant (56.67%), and high-ETosis (83.33%) groups (P = 0.005). CONCLUSIONS: The results of this study suggest that tissue Eosinophilia and EETosis may play a prognostic role, primarily in CRSwNP and thattissue neutrophilia and NETosis can play as prognostic biomarkers in neutrophilic CRSwNP.